Provider Demographics
NPI:1093155103
Name:KEPPOL, STACEY (OD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KEPPOL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3010
Mailing Address - Fax:206-858-7050
Practice Address - Street 1:2606 116TH AVE NE STE 100
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-1422
Practice Address - Country:US
Practice Address - Phone:425-462-7664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-03
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60840014152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2096921Medicaid
PA12564332OtherCAQH PROVIDER NUMBER